This week, the World Health Organization (WHO) launched an ambitious plan to sharply reduce tuberculosis (TB) infections in 33 rich countries, where overall infection levels are low but TB thrives among the homeless, migrants, prisoners, drug users, heavy drinkers and people with HIV/AIDS.
The goal is to reduce the infection rate by a factor of 10 to fewer than 10 new TB cases per million people per year by 2035 in each of the 33 targeted nations, and to eliminate it by 2050. “If elimination is achieved in these countries with relatively low rates of infection, the strategy will be replicated in countries such as India, China and South Africa, where infection runs into several hundred-thousands,” said Dr. Mario Raviglione, director of the WHO’s Global TB Programme. TB elimination is defined as less than one case per 100,000 people.
The WHO TB- elimination strategy involves broader screening for both active and latent TB infections in high-risk groups, funding high-quality health services, and investing in new drugs, vaccines and diagnostic tests to ensure TB is diagnosed and treated at the onset, which lowers the chances of it turning resistant to drugs.
TB is caused by Mycobacterium tuberculosis and spreads through air through droplets from persistent coughing, which is among the symptoms that include fatigue, weight loss, shortness of breath, night sweats and chest pain.
By the end of 2011, an estimated 8.7 million developed TB and 1.4 million died of it, globally, estimates the WHO. Of the 450,000 who fell ill with dangerous superbug strains in 2012, and up to 2 million may be infected with drug-resistant TB by 2015, it says. TB is a leading killer of people who have a compromised immunity, such as people infected HIV. If untreated, an infected person can infect 10 or more people in one year. India accounts for 26% of the 8.7 million of global cases, followed by China with 12%.
TB, which continues to kills more people than AIDS, sexually-transmitted diseases, malaria, leprosy and tropical diseases combined, can easily be controlled using first-line drugs, with the cost of treatment per person beginning at Rs. 600 per person under the India’s Revised National TB Control Programme (RNTCP).
“But if a person develops drug resistance, treatment costs shoot up substantially, with treating one person with XDR (extensively drug-resistant) costing up to Rs. 2.7 lakh,” said a union health ministry official, who did not wish to be named because he’s not authorised to speak to the media. More than 25,000 people in India were being treated free for multidrug- resistant (MDR) TB, till March 2013, a sharp jump from 14,059 in 2012 (2.2%), though it is still low compared to worldwide prevalence of 3.7% new cases.
And, with an annual budget of Rs 710 crore, the RNTCP tested 55 million people and treated 15.8 million since its inception in 1997.
Ensuring better compliance to the complete treatment regimen is Nikshay, India’s digital database to track and manage the treatment of mobile populations being treated free.
It enables near real time reporting of new cases for optimal case management of people who do not go back to the same health centre for follow-up treatment.
TB was made a notifiable disease in May 2012, which makes it mandatory for all private hospitals and clinics to report cases to the government. “The biggest challenge, however, remains regulating the private sector, where doctors and quacks continue to prescribe medicines in wrong strengths and combinations,” says the health ministry official. “Many people reach the government programme after their infection has persisted or worsened because of wrong prescription and treatment in the private sector,” he adds.
Add to this the high cost of treating MDR and XDR in the private sector and you have people stopping treatment soon after their symptoms disappear, which happens within the first few months.
As much as standards for TB care, what is needed is better regulation of the private sector if it wants the TB-control programme to stay on track. For, without treatment, 70% of those infected die within 10 years of diagnosis, reports the Global TB Report 2012.
Treating uncomplicated TB involves using a six-month regimen of four first-line drugs. Treating MDR-TB takes up to 18 to 24 months and requires the use of more expensive and toxic drugs.
All TB drugs recommended by the WHO are currently out of patent-protection and freely manufactured by generic bulk drug companies.
In an important first step towards developing new drugs for antibiotic-resistant TB, scientists in India and the US last week successfully modified the precursor to one of the drugs used to treat TB. The findings indicate that a new compound, 24-desmethylrifampicin, has much better antibacterial activity than rifampicin against MDR strains of the bacteria that cause tuberculosis. Rifampicin and related drugs are important antibiotics, the key to the drug cocktail used to cure TB, but MDR and XDR are resistant to rifampicin.
The first new TB treatment in more than 40 years, Johnson & Johnson’s bedaquiline, was approved in 2012 for use on drug-resistant TB, and in 2013 the European Medicines Agency recommended granting conditional marketing approval for delamanid, developed by Otsuka in Japan.
Besides new drugs, about a dozen promising vaccines are currently being tested, mostly by US and UK, with some expected to be in the market by 2022.